Balestra, Gianmarco M.

Christ, Michael

Di Valentino, Marcello

Oertli, Daniel

Raineri, Ines

Zellweger, Michael J.

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CLINICAL VIGNETTE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .doi:10.1093/eurheartj/ehm449Online publish-ahead-of-print 21 October 2007Inverted Takotsubo cardiomyopathy due to pheochromocytomaMarcello Di Valentino1, Gianmarco M. Balestra2, Michael Christ2, Ines Raineri3, Daniel Oertli4,and Michael J. Zellweger1*1Department of Cardiology, University Hospital, Petersgraben 4, CH-4031 Basel, Switzerland; 2Department of Internal Medicine, University Hospital, Basel, Switzerland;3Department of Pathology, University Hospital, Basel, Switzerland; 4Department of Surgery, University Hospital, Basel, Switzerland* Corresponding author. Tel: þ41 61 265 5473; Fax: þ41 61 265 4598. Email: mzellweger@uhbs.chA 52-year-old woman with history of weightloss and hypertension was referred to our car-diology department with acute typical chestpain, shortness of breath, hypertensive crisis(180/120 mmHg) and headache. The ECGshowed sinus tachycardia with ST-segmentdepression in precordial leads V4–V6. Tropo-nin T level as well as creatin kinase were elev-ated to 4.06 mg/L (normal ,0.01 mg/L) and266 U/L (normal 38–157 U/L), respectively.Because of these findings and ongoing chestpain the patient underwent emergency coron-ary angiography that excluded obstructivecoronary artery disease (Panels A and B).However, ventriculography revealed aseverely depressed left ventricular ejectionfraction (LVEF 20%) with akinetic basal andmidventricular segments (Panels C and D,arrows) and a hyperkinetic apex (arrow-heads), findings consistent with an invertedTakotsubo cardiomyopathy. Twenty-fourhours later a transthoracic echocardiographydemonstrated an improvement in LVEF(40%). Cardiac magnetic resonance, taken 3days after admission, revealed a normalizedLVEF of 60% without wall motion abnormal-ities. Given the clinical history, the normalresult of the coronary angiography, and therapid normalization of the heart function, a pheochromocytoma was suspected. Serum total Metanephrine was 51 nmol/L (normal 2.03–4.16 nmol/L) and free Metanephrine was 5 nmol/L (normal 0.06–0.61 nmol/L). Abdominal computer tomography revealed a right adrenal mass. After pre-treatment with alpha and beta blockade the patient underwent an uncomplicated adrenalectomy (Panel E). Histological and immunohistochemical stain-ing confirmed the diagnosis of pheochromocytoma (Panels F and G). The postoperative course was uneventful.Panels A and B. Shows normal right and left coronary arteries.Panels C and D. End-systolic (C) and end-diastolic (D) left ventriculography showed akinesia of the basal and midventricular segments (arrows) andapical hypercontractility (arrowheads).Panel E. Right adrenal gland. The tumour (4  3  2.5 cm3) contains areas of necrosis and haemorrhage (arrows).Panel F. Hematoxylin and eosin staining reveals polygonal cells with fibrous tracts.Panel G. Positive chromogranin staining.Published on behalf of the European Society of Cardiology. All rights reserved.& The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org.830 Clinical vignette

Inverted Takotsubo cardiomyopathy due to pheochromocytoma

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